Provider Demographics
NPI:1477598373
Name:KULAGA, ELISE ELLEN (PA)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:ELLEN
Last Name:KULAGA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:ELLEN
Other - Last Name:GROBELNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5 RADIO RD
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-2881
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:FLORIDA HOSPITAL FLAGLER
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5980
Practice Address - Country:US
Practice Address - Phone:386-586-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2013-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103202363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q47778Medicare UPIN
NJ092723WJ8Medicare PIN
NJ092723Medicare ID - Type Unspecified